Updated 7:17 am, Wednesday, April 9, 2014

The annual physical has been cast as both an essential benefit for preventive care and an unnecessary cost that overtaxes an already burdened system without making people healthier.

Now that the routine checkup is covered under the federal Affordable Care Act as well as Medicare, that debate is likely to heat up.

"The annual physical - the annual part - is where the current tension applies," said Dr. Edward Yu, a family practice doctor and the Palo Alto Medical Foundation's lead physician on quality measures. "Now with the ACA, more patients have access to insurance that allows them to see the doctor. From our end, there will be more patients coming into the health care system."

More than 7 million Americans have signed up for health insurance under the Affordable Care Act through the new federal or state-run exchanges, including more than 1.2 million Californians who have enrolled in Covered California.

Among a list of essential benefits that all health plans have to cover without requiring co-payments is the annual physical. That's on top of a decision by Medicare, the federal health program primarily for people 65 and older, to pay for yearly exams beginning in January 2012.

The trouble is, say critics of the annual exam, the procedure may do more harm than good, and they point to studies to bolster their point.

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A 2012 examination of various trials conducted around the world that compared people who received health checks and those who didn't found routine exams did nothing to reduce deaths, hospitalizations or medical costs.

More harm than good?

The study by scientists at the Nordic Cochrane Centre in Copenhagen supported decades-old research by the Canadian government, which deemed the annual physical "nonspecific" and even "potentially harmful." A Canadian government task force in 1979 recommended replacing the physical with periodic screening based on risk factors.

While common wisdom might suggest that catching a potential health problem early might prevent it from becoming a bigger, more expensive problem later, that's not how it pans out, said Dr. Jay Bhattacharya, an associate professor of medicine at Stanford University and a health economist.

"It's not just the cost of the annual physical," he said. "It's the things the annual physical leads to. The annual physical will lead to people having more medical problems and more medical testing, much of which is not necessary."

Age-, gender-specific tests

The U.S. Preventive Services Task Force and several physician organizations remain somewhat agnostic on the practice, neither recommending nor discouraging yearly exams. Kaiser Permanente officials said it leaves whether to have an annual physical up to physicians and their patients.

But even those tests get murky as study after study debates the frequency of mammograms in women or whether PSA, or prostate-specific antigen blood tests, should be done on healthy men. Sometimes it's hard to know when to get these screenings done, doctors said, especially in the absence of an annual physical.

"Traditionally, that's been how these preventive health services are delivered," explained Yu, of the Palo Alto Medical Foundation. "A physical exam or physical checkup itself is not the most important component of (prevention). It's receiving these services."

One of Yu's patients, Sidney Chen, came in for his physical exam on Monday.

Chen, a property manager who lives in Menlo Park, used to be vigilant about going in each year for a checkup. But that was more than 15 years ago, when he learned his cholesterol and blood pressure were high.

"The alarm bells went off and the hypervigilance kicked in for a bit," said Chen, who is now 53.

But he was stabilized on medications, improved his diet and took up long-distance running. Chen said he now opts for a physical every three years.

Chen said he tracks his blood pressure and has annual blood tests to monitor the effect of his medications, but doesn't go in for an appointment unless something comes up, which is infrequent. If he needs to ask a question, he said he typically communicates with his doctor via e-mail.

Establishing a baseline

He said a baseline physical is important for a patient establishing a relationship with a new doctor.

"Everyone needs an initial visit. You could look perfectly healthy and have cholesterol that's sky-high. You may not know what your blood pressure is if you've never had it checked," Dressner said. "Depending on what comes out of that, you may not need to come in yearly."

In fact, Dressner said he wouldn't want to see a healthy, relatively young person every year. "If every single person went to the doctor every year, we would overwhelm the system and not be able to take care of the chronically ill," he said.

Even annual blood tests, which may sound like a prudent thing to do, aren't necessary for a healthy person who is not monitoring a chronic condition, he said.

"If you test too much, something will come out abnormal even when it's not," Dressner said.

Some variation in tests may be perfectly normal, he said, but it requires further testing to find out whether anything is truly wrong.

Ironically, Dressner is required to have an annual physical exam as a condition of his employment.

"I'm basically healthy and there's nothing much to do," he said. "The only reason I come in is to have him sign my form."

Getting a physical

While debate continues on whether an annual physical is of merit, there are a number of age- and gender-specific screenings that most health professionals recommend. Doctors still have different ideas about the timing and value of some of the screenings. Here are some of the most commonly recommended tests:

Blood pressure testing: Recommended every two years for both men and women if normal; yearly or more often if higher.

Osteoporosis: A bone mineral density test is recommended at least once for women over 65; younger women should talk to their doctor about their risk and whether they need earlier screening.

Cholesterol tests: A baseline is recommended at age 20 for both men and women. The frequency of regular screenings is based on risk factors for heart disease.

Cervical cancer screening: No longer recommended annually. Generally, Pap and HPV (human papillomavirus) tests are done together every five years for most adult women.

Breast cancer screening: Mammograms are covered under the Affordable Care Act for women over 40. Women need to discuss the frequency and screening options with their doctors. This is an area of great debate.

Diabetes screening: Screening is recommended for anyone with high blood pressure.

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